Predicting Changes in Depressive Symptoms from Pregnancy to Postpartum: The Role of Brooding Rumination and Negative Inferential Styles

 
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Cogn Ther Res (2013) 37:71–77
DOI 10.1007/s10608-012-9456-5

 ORIGINAL ARTICLE

Predicting Changes in Depressive Symptoms from Pregnancy
to Postpartum: The Role of Brooding Rumination
and Negative Inferential Styles
Sarah E. Barnum • Mary L. Woody          •

Brandon E. Gibb

Published online: 11 April 2012
Ó Springer Science+Business Media, LLC 2012

Abstract The current study examined the role of cogni-         Introduction
tive factors in the development and maintenance of
depressive symptoms from pregnancy into the postpartum         Researchers estimate that approximately 7 % of women
period. One hundred and one women were assessed for            meet criteria for major depression in the first 3 months
levels of rumination (brooding and reflection), negative       postpartum (O’Hara 2009). Even more new mothers (up to
inferential styles, and depressive symptoms in their third     70 %) experience postpartum blues, a milder level of
trimester of pregnancy and depressive symptom levels           sadness and associated depressive symptoms, which often
again at 4 and 8 weeks postpartum. We found that,              remits within the first 10 days postpartum (Whiffen 1991;
although none of the three cognitive variables predicted       Gotlib et al. 1989). In fact, 45–65 % of women report
women’s initial depressive reactions following childbirth      experiencing their first depressive episode within 1 year of
(from pregnancy to 1 month postpartum), brooding rumi-         giving birth (Moses-Kolko and Roth 2004). Furthermore,
nation and negative inferential styles predicted longer-term   infants, toddlers, and school-age children of mothers with
depressive symptom changes (from pregnancy to 2 months         postpartum depression are at risk for problems with emo-
postpartum). However, the predictive validity of women’s       tion regulation, behavioral and psychological problems,
negative inferential styles was limited to women already       insecure attachments, and delays in cognitive and language
exhibiting relatively high depressive symptom levels dur-      development (Beck 1996; Murray and Cooper 1997). This
ing pregnancy, suggesting that it was more strongly related    risk may be heightened with the mother’s subsequent
to the maintenance of depressive symptoms into the post-       depressive episodes (Philipps and O’Hara 1991). Given
partum period rather than increases in depressive symp-        that risk for future episodes increases with each depressive
toms following childbirth. Modifying cognitive risk            episode experienced (Solomon et al. 2000), these findings
factors, therefore, may be an important focus of interven-     suggest that the childbearing years may present a unique
tion for depression during pregnancy.                          opportunity for prevention and may be a time when vul-
                                                               nerable women and their families are likely to be at highest
Keywords Postpartum depression  Rumination                   risk (Philipps and O’Hara 1991).
Inferential style  Risk  Maintenance                            A number of researchers have focused on risk factors for
                                                               postpartum depression; however, this research has gener-
                                                               ally proceeded separately from the larger depression liter-
                                                               ature and has typically focused on factors related to the
                                                               pregnancy itself (e.g. obstetric complications or hormone
                                                               levels) or demographic factors (such as previous history of
                                                               psychopathology, socioeconomic status, and parity), with-
                                                               out grounding these investigations in existing theories of
S. E. Barnum  M. L. Woody  B. E. Gibb (&)
                                                               depression (cf. Whiffen and Gotlib 1993). Although there
Department of Psychology, Binghamton University (SUNY),
Binghamton, NY 13902-6000, USA                                 is substantial individual variability, childbirth and taking
e-mail: bgibb@binghamton.edu                                   care of a new born are stressful. Therefore, broader

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vulnerability-stress theories of depression may help to         formally evaluated the hopelessness theory within the
increase our understanding of which women may be at             context of postpartum depression. This said, there is evi-
greatest risk for depression postpartum. Much of the            dence that one of the three inferential styles featured in the
research on depression risk more generally has focused on       hopelessness theory—negative attributional styles for the
cognitive risk factors. Two of the primary cognitive theo-      causes of negative events as defined in the hopelessness
ries of depression are the hopelessness theory and the          theory’s predecessor, the reformulated theory of learned
response styles theory. In the hopelessness theory of           helplessness (internal, stable, global attributions; Abram-
depression (Abramson et al. 1989), cognitive vulnerability      son et al. 1978)—is associated with postpartum depressive
to depression is defined as the tendency to attribute nega-     symptoms (for a review, see O’Hara and Swain 1996). In
tive events to stable, global causes and to infer negative      each of these studies, however, it is unclear whether cog-
consequences and self-characteristics following the occur-      nitive risk factors predict increases in depressive symptoms
rence of negative events. An example of this type of neg-       following childbirth (development of symptoms) or whe-
ative inferential style would be the explaining the             ther they predict the maintenance of depressive symptoms
occurrence of a negative event in one’s life by saying ‘‘I’m    from pregnancy into the postpartum period. Across studies,
worthless and can’t do anything right’’. This type of           levels of depressive symptoms during pregnancy are one of
explanation reflects an attribution of the cause of the event   the most salient predictors of postpartum depression (cf.
to stable (unlikely to change) and global (likely to affect     O’Hara et al. 1991). In fact, forty to fifty percent of
many areas of one’s life) factors and implies negative          mothers who experience postpartum depression have sig-
consequences (additional negative events in the future) and     nificant symptoms of depression during their pregnancy
negative self-characteristics about the individual. With        (Whiffen 1992; Yonkers et al. 2001).
regard to the response styles theory (Nolen-Hoeksema               Our goal in the current multi-wave prospective study,
1991), the tendency to respond to negative mood by              therefore, was to determine whether the vulnerabilities
ruminating (or repetitively thinking about why one is           featured in the hopelessness theory of depression (negative
feeling sad or depressed and the consequences of depres-        inferential styles) and the response styles theory (brooding
sive symptoms) is hypothesized to contribute to the             and reflection) could help to explain risk for postpartum
development and maintenance of depression. Although             depressive symptoms. In so doing, we specifically exam-
early work testing the response styles theory focused on        ined the development versus maintenance of depressive
rumination generally, more recent research has focused on       symptoms from pregnancy to postpartum. We also exam-
two distinct components of rumination, brooding and             ined women’s functioning at two time points postpartum—
reflective pondering. Brooding is defined as ‘‘a passive        1 month and 2 months postpartum—to gain a better
comparison of one’s current situation with some unac-           understanding of relatively short-term versus longer-term
hieved standard’’ whereas reflection is defined as ‘‘a pur-     changes in depressive symptoms.
poseful turning inward to engage in cognitive problem-
solving to alleviate one’s depressive symptoms’’ (Treynor
et al. 2003, p. 256). There is growing evidence that            Method
brooding and reflective rumination are distinct constructs
and that brooding represents a more maladaptive form of         Participants
rumination than reflection, with stronger links to depres-
sion (for a review, see Nolen-Hoeksema et al. 2008).            Participants were 101 women in their third trimester of
   Both the hopelessness theory and the response styles         pregnancy. Women were only excluded if they were under
theory have garnered considerable support for predicting        the age of 18 or were unable to read and write in English.
the development and maintenance of depressive symptoms          The average age of participants in this study was
and diagnoses in general community samples (for reviews,        28.44 years (SD = 6.39), and 89 % were Caucasian. Par-
see Haeffel et al. 2008; Nolen-Hoeksema et al. 2008).           ticipants were generally well educated (53.5 % had a col-
However, only one study of which we are aware has               lege degree or higher) and had a median yearly household
examined the link between rumination and postpartum             income of $55,000 (range: \$5,000–[$200,000 per year).
depressive symptoms (O’Mahen et al. 2010). This study           Fifty-five percent of participants were pregnant with their
focused on women with elevated depressive symptom               first child and 73.5 % were currently married.
levels during pregnancy and found that levels of brooding
rumination predicted residual change in depressive symp-        Measures
toms from pregnancy to three months postpartum among
women with low but not high social functioning during           Levels of rumination were assessed with the Ruminative
pregnancy. In addition, no study of which we are aware has      Response Scale (RRS; Treynor et al. 2003). The RRS is a

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self-report questionnaire that asks participants to rate the                The Edinburgh Postnatal Depression Scale (EPDS; Cox
frequency with which they think or do certain things when                et al. 1987) is a 10 item self-report questionnaire of
they feel sad, down, or depressed (e.g., ‘‘Go some place                 depressive symptoms in pregnancy and the postpartum
alone to think about your feelings’’). The statements are                period. Individuals are asked to circle one of four responses
rated on a 4-point Likert-type scale from almost always to               for each item, which correspond to increasing symptom
almost never. Given concerns that some of the RRS items                  severity. Responses to items are summed to create a total
overlap with depressive symptoms, factor analytic studies                score (maximum of 30), with higher numbers indicating
have identified two subscales of the RRS—brooding and                    more severe symptoms. The EPDS was designed to be a
reflection—which are not confounded with depressive                      screening measure specifically for postpartum women and
content (Treynor et al. 2003). The current study focused on              deemphasizes the somatic symptoms of depression, which
these two subscales. Both 5-item subscales have demon-                   are often experienced due to the pregnancy and birth alone.
strated good psychometric properties in previous research;               A cutoff score of 12 or higher exhibits good sensitivity
however, as noted above, the brooding subscale is more                   (86 %) and specificity (78 %) in detecting depressive
strongly related to depression and related constructs                    diagnoses in postpartum women (Cox et al. 1987). The
(Nolen-Hoeksema et al. 2008). In the current study, the                  EPDS has been validated for use in both prenatal and
brooding and the reflection subscales exhibited adequate                 postnatal women. The EPDS has been shown to be reliable
internal consistency (as = .82 and .76, respectively).                   and valid across a number of studies (Evins and Theo-
   Women’s negative attributional styles were assessed                   frastous 1997), displays good sensitivity and specificity
with the Expanded Attributional Style Questionnaire (Pet-                (Eberhard-Gran et al. 2001; Evins and Theofrastous 1997),
erson and Villanova 1988).1 The EASQ is a self-report                    is sensitive to changes over time (Cox et al. 1987) and is
questionnaire that presents 12 hypothetical negative events.             acceptable to administer over the phone (Zelkowitz and
For each event, the individual is asked to write down what               Milet 1995). The EPDS demonstrated good internal con-
she believes would have been the cause of that event and                 sistency (as = .85, .81, and.83 at T1–T3, respectively).
then to rate that cause in terms of its internality, stability,
and globality. The EASQ was modified for the current                     Procedure
study in two ways. First, questions were added for each
hypothetical event to assess the other two inferential styles            Pregnant women in their third trimester were recruited for
featured in the hopelessness theory—negative inferential                 this study via advertisements in the local newspaper, flyers
style for the consequences and self-worth implications of                at local obstetrician’s offices, and information posted on
each event (i.e., ‘How likely is it that the [negative event]            online parenting groups for new mothers. After giving
will lead to other negative things happening to you?’ and                informed consent, participants completed the Time 1 study
‘To what degree does the [negative event] mean that you                  questionnaires (M = 49 days [SD = 28] before the baby’s
are flawed in some way?’). In addition, to reduce partici-               birth). Participants then completed measures of depressive
pant burden, only the first six hypothetical negative events             symptoms over the phone approximately 1 month
from the EASQ were used in this study. Previous research                 (M = 35 days [SD = 13]) and 2 months (M = 65 days
has found that equivalent concurrent and predictive validity             [SD = 13]) postpartum. Mothers were compensated $25
are obtained using these six items as with the full EASQ                 for their participation.
(Whitley 1991). Consistent with other research testing the
hopelessness theory (see Haeffel et al. 2008), we created a
composite score by averaging participants’ inferences                    Results
regarding causes (stability and globality ratings), conse-
quences, and self-implication ratings for each of the                    Of the 101 women who completed the initial assessment,
hypothetical negative events. For this composite, higher                 91 completed the Time 2 assessment and 93 completed the
scores indicate more negative inferential styles. The neg-               Time 3 assessment. Given the presence of missing data, we
ative inferential style composite score exhibited good                   examined whether the data were missing at random,
internal consistency in this study (a = .87).                            thereby justifying the use of data imputation methods for
                                                                         estimating missing values (cf. Shafer and Graham 2002).
1
   Although negative inferential styles in adults are most commonly      Little’s missing completely at random (MCAR) test, for
assessed with the Cognitive Style Questionnaire (Haeffel et al. 2008),   which the null hypothesis is that the data are MCAR (Little
five of the 12 hypothetical negative events on this scale focus on       and Rubin 1987) was nonsignificant, v2(67) = 65.74,
school work/academic performance, which may be less relevant for a
                                                                         p = .52. Given this, Multiple Imputation was used to
general community sample of expectant mothers. Therefore, we chose
to use the EASQ instead because it focuses more broadly on negative      generate 20 imputed dataset, which were used in all sub-
events that may be more typical for a community sample.                  sequent analyses. Following the standard approach, the

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results presented reflect the pooled estimates across these                     regressions by adding them in block 2 of the regressions.
data sets. This approach yields more reliable parameter                         Consistent with the recommendations of Joiner (1994), we
estimates than other methods of dealing with missing data,                      also examined interactions between the cognitive variables
including single imputation methods (see Shafer and Gra-                        and T1 EPDS scores to determine whether the cognitive
ham 2002). Descriptive statistics and correlations among                        variables predicted the development versus maintenance of
the study variables are presented in Table 1. We should                         depressive symptoms into the postpartum period. None of
also note that although the mean level of depressive                            these analyses were significant, indicating that none of the
symptom decreased across the follow-up, women reported                          cognitive risk factors predicted women’s short-term
a wide range of symptoms on the EPDS at all three                               depressive reactions during the postpartum period (lowest
assessment points (0–22 at Time 1; 0–20 at Time 2 and 3).                       p = .30).
Also, 21 % of women scored above the suggested cutoff of                           In contrast, the cognitive risk factors did predict longer-
12 (Cox et al. 1987) at Time 1, 7 % scored above this                           term depressive symptom changes. Specifically, levels of
cutoff at Time 2, and 5 % scored above the cutoff at Time                       brooding rumination assessed during the third trimester
3. Therefore, although drawn from the community, there                          predicted residual change in depressive symptom between
was a meaningful range of depressive symptoms displayed                         the third trimester and 2 months postpartum (T1–T3),
in our sample.                                                                  t(98) = 2.81, p = .005, pr = .28. The interaction between
   Next, hierarchical regression analyses were used to                          brooding rumination and initial depressive symptom levels
examine short term changes in women’s depressive                                was not significant, t(97) = 1.02, p = .31, pr = .12, sug-
symptoms from the third trimester to 1 month postpartum                         gesting that the predictive validity of brooding rumination
(T1–T2). For these analyses, T2 EPDS scores served as the                       was similar for women exhibiting higher and lower
criterion variable and T1 EPDS scores were entered as a                         depressive symptom levels at the initial assessment. The
covariate in block 1 of the regression, allowing us to                          results of this analysis are plotted in Fig. 1, which shows
examine residual change in depressive symptoms from T1                          the relation between baseline levels of brooding rumination
to T2. As noted above, we also included women’s marital                         and residual change in depressive symptoms from T1 to
status and number of children as covariates in these anal-                      T3. As can be seen in the figure, although levels of
yses. The cognitive risk factors were examined in separate                      depressive symptoms decreased over the follow-up for the

Table 1 Correlations and descriptive statistics for study variables
                            1          2         3         4          5           6         7          8         9           10       11        12

1.      T1 EPDS              –
2.      T2 EPDS                  .41   –
3.      T3 EPDS                  .48       .56   –
4.      EASQ                     .35       .24       .23   –
5.      RRS-brooding             .61       .26       .48       .42    –
6.      RRS-reflection           .54       .23       .35       .22        .54      –
7.      Age                 -.25       -.24      -.31      -.17       -.13        -.15       –
8.      Caucasian           -.08       -.06      -.09      -.02       -.04        -.15           .17   –
9.      Income              -.49       -.06      -.40      -.13       -.35        -.33           .40       .21   –
10      Marital status      -.50       -.23      -.42      -.09       -.31        -.34           .40       .11       .48     –
11.     Children (#)             .01   -.30      -.17      -.02       -.04        -.04           .42       .08   -.03         .05     –
12.     Miscarriage              .19   -.01          .07       .00        .15         .03        .06       .02   -.04        -.11         .05   –
        Mean                 8.07      5.96      4.53      3.33       9.56         8.85     28.81      –         –           –        –         –
        SD                   4.76      4.11      4.12       .88       3.44         3.17      2.20      –         –           –        –         –
        Median               –         –         –         –          –            –         –         –         $55 K       –        0         –
        %                    –         –         –         –          –            –         –         90 %      –           74 %     –         23 %
EPDS Edinburgh Postnatal Depression Inventory, EASQ Expanded Attributional Style Questionnaire, RRS-Brooding Ruminative Response
Scale—Brooding subscale, RRS-Reflection Ruminative Response Scale—Reflection Subscale. Caucasian was coded so that 1 = Caucasians and
0 = other racial/ethnic groups. Marital status was coded so that 1 = married 0 = unmarried. Children = number of children for each mother
prior to the index pregnancy. Miscarriage was coded so that 1 = prior miscarriage and 0 = no history of miscarriage
Correlations C |.22| significant at p \ .05. Correlations C |.26| significant at p \ .01. Correlations C |.31| significant at p \ .001

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                                                                                                          High EASQ   Low EASQ
                                                                                                0

                                                                       Symtpoms from T1 to T3
                                                                        Change in Depressive
                                                                                                -1

                                                                                                -2

                                                                                                -3

                                                                                                -4

                                                                                                -5

                                                                                                -6

                                                                                                -7
                                                                                                     Low T1 EPDS       High T1 EPDS

                                                                      Fig. 2 Summary of inferential styles 9 T1 depressive symptoms
                                                                      predicting change in depressive symptoms from the T1 (3rd trimester)
                                                                      to T3 (2 months postpartum) assessment. EASQ Expanded Attribu-
                                                                      tional Style Questionnaire. EPDS Edinburgh Depression Rating Scale

                                                                      controlling for the potential influence of women’s age,
                                                                      race, marital status, family income, number of other chil-
                                                                      dren in the home, and history of miscarriage, Time 1 levels
                                                                      of brooding rumination continued to significantly predict
Fig. 1 Prediction of residual change in depressive symptoms from      residual change in women’s depressive symptoms from the
the T1 (3rd trimester) to T3 (2 months postpartum) assessment. RRS-   third trimester of pregnancy to 4 months postpartum,
Brooding Ruminative Response Scale-Brooding subscale                  t(92) = 2.75, p = .006, pr = .28. Similarly, controlling
                                                                      for each of these demographic variables, women’s infer-
majority of women, those with high levels of brooding                 ential styles continued to predict changes in depressive
rumination experienced an increase in depression during               symptoms among those with relatively high depressive
the postpartum period.                                                symptom levels at the initial assessment, t(91) = 2.73,
    We also found a significant EASQ 9 T1 EPDS inter-                 p = .006, pr = .29.
action predicting T3 depressive symptoms, t(97) = 3.35,
p = .001, pr = .34. Examining the form of this interaction
(cf. Aiken and West 1991), we found that women’s infer-               Discussion
ential styles predicted residual change in depressive
symptoms among those exhibiting relatively high (?1 SD),              The goal of this study was to determine the ability of two
t(97) = 2.98, p = .003, pr = .31, but not low (-1 SD),                leading cognitive theories of depression—hopelessness
t(97) = -1.40, p = .16, pr = -.15, depressive symptoms                theory and response styles theory—to explain postpartum
at the initial assessment. As can be seen in Fig. 2, although         depression risk. Adding to the growing body of depression
the majority of women experienced decreases in depressive             research suggesting the important role of brooding rumi-
symptom across the follow-up, those with negative infer-              nation (Nolen-Hoeksema et al. 2008; O’Mahen et al. 2010),
ential styles and relatively high levels of depressive                we found that levels of brooding rumination predicted
symptoms during their third trimester of pregnancy main-              residual change in women’s depressive symptoms from the
tained their levels of depressive symptoms across the fol-            third trimester of pregnancy to 2 months postpartum, even
low-up (average EPDS in this group at T3 = 7.60). In                  after statistically controlling for the influence of demo-
contrast, levels of reflective rumination did not predict             graphic variables. Also, adding to the existing literature
residual change in depressive symptoms from T1 to T3,                 suggesting that brooding rumination is a more maladaptive
either as a main effect, t(98) = 1.18, p = .24, pr = .12, or          form of rumination than reflection (see Nolen-Hoeksema
interacting with T1 depressive symptom levels,                        et al. 2008), the effects were specific to brooding. Although
t(97) = 0.43, p = .67, pr = .05.                                      reflective rumination was significantly related to depressive
    Finally, given the strong links observed in previous              symptoms concurrently during pregnancy, it did not predict
studies between demographic characteristics and risk for              prospective changes in these symptoms. We also found
(postpartum) depression, we conducted additional analyses             some support for the hopelessness theory. Specifically,
to determine whether the results reported above would be              women’s negative inferential styles also predicted depres-
maintained even after statistically controlling for the               sive symptom levels at 2 months postpartum. However,
influence of demographic variables. Even after statistically          this finding was limited to women who already had

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elevated depressive symptom levels during their third tri-        of cognitive vulnerability to depression can be applied to
mester, suggesting that inferential styles predicted the          the prediction of postpartum depression risk, the multi-
maintenance of symptoms present during the third trimes-          wave prospective design, and the specific examination of
ter rather than the development of new symptoms                   depressive symptom increases following childbirth versus
postpartum.                                                       maintenance of depressive symptoms from pregnancy to
    In contrast to these results, none of the cognitive vari-     postpartum. The study also had several limitations that
ables predicted residual change in depressive symptoms            highlight important areas for future research. First, all of
from pregnancy to 1 month postpartum. The reason for this         the assessments relied upon women’s self-reports, which
difference in finding is unclear and certainly warrants           could have been subject to recall or response bias. Also, the
additional investigation. One possibility is that shorter-term    mono-method assessment could have inflated relations
depressive reactions are more strongly influenced by con-         among the study variables. Future studies testing cognitive
textual factors (e.g., health of baby, availability of social     models of depression risk, therefore, would benefit from the
support, etc.) and that the predictive power of cognitive         inclusion of interviewer-administered measures of depres-
risk factors emerges only after this initial period of            sive symptoms. Second, although this study focused on
adjustment. Again, future research is need to more clearly        leading theories of cognitive vulnerability to depression, we
understand influences on shorter- versus longer-term              recognize that there are multiple levels of influence in
depressive reactions following child birth.                       women’s depression risk during pregnancy and postpartum,
    Another finding from this study that warrants discussion is   which we did not assess for in this study. Third, building from
that women exhibited the highest levels of depressive             cognitive vulnerability-stress models of depression risk, we
symptoms during pregnancy (with 21 % of women scoring             conceptualized childbirth as a common stressor shared by all
above the suggested cutoff of 12 on the EPDS). For the            the women in our sample. However, the stress associated
sample as a whole, these symptoms reduced across the fol-         with labor/delivery and with taking care of a newborn
low-up. However, there was significant variability in this        obviously varies considerably across families. Therefore, to
pattern, with approximately 5 % of women still scoring            provide a more powerful test of the cognitive models, future
above the cutoff on the EPDS at 2 months postpartum, which        research should include a more detailed assessment of the
is consistent with rates of postpartum depression observed in     contextual stress experienced by each woman so that these
previous research (for a review, see O’Hara 2009). The cur-       idiographic differences can be captured.
rent results suggest that cognitive models of depression may         In summary, the current results provide strong support
help to account for which women will maintain their               for the role of cognitive risk factors in postpartum
depression following pregnancy (inferential styles) as well as    depressive symptoms. They also suggest that inferential
those at risk for experiencing depressive symptom increases       styles and brooding rumination may play different roles in
postpartum (brooding rumination). Cognitive models,               women’s depression risk (maintenance and development of
therefore, may provide an important area of intervention, as      depressive symptoms, respectively). Importantly, however,
many other known risk factors (such as demographic factors)       the current results suggest that many women are already
are often difficult to modify during pregnancy.                   experiencing clinically significant levels of depressive
    The current results also raise an interesting and impor-      symptoms by their third trimester. Future research, there-
tant question. When is the best time to assess risk and           fore, should focus earlier in pregnancy to determine the
intervene to reduce depression in pregnant women? To the          most effective window during which to identify at-risk
extent that depressive symptoms are already elevated by           women before they develop depression.
the third trimester, this suggests the utility of earlier
screening for depression and depression risk. Indeed, a           Acknowledgments This project was supported by National Institute
                                                                  of Child Health and Human Development grants HD048664 and
limitation of this study is that we did not conduct our initial   HD057066 awarded to B.E. Gibb.
assessment until the third trimester of women’s pregnan-
cies. Future research is needed to examine risk precon-
ception and then throughout pregnancy to determine at
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